Active septic arthritis of the hip in adults: what's new in the treatment? A systematic review

Diagnosis and surgical treatment of chronic destructive septic hip arthritis

Septic hip arthritis (SHA) is a relatively rare but hazardous disease. Much controversy exists regarding the definition, diagnosis and treatment of chronic destructive SHAs. This review aims to provide an overview of the diagnostic and therapeutic approaches for chronic, destructive SHA and suggest possible research directions for this disease's future diagnosis and treatment. There is no unified naming or classification standard for SHAs. Chronic destructive SHA still requires a comprehensive diagnosis combining history, signs, bacterial culture, histopathological examination, inflammation and other indicators, of which metagenomic next-generation sequencing is a promising diagnostic tool. Previous treatment options for this disease include debridement, debridement + Girdlestone femoral head and neck resection, and debridement + Girdlestone femoral head and neck resection + two-stage arthroplasty. Among them, one-stage spacer implantation + two-stage arthroplasty is the current standard surgical option with a high success rate and low reinfection rate, while one-stage arthroplasty is a new treatment option proposed in recent years with unique advantages but limitations in terms of surgical indications. In the future, more high-quality studies are needed to provide the latest evidence to support clinical decision-making.

Staphylococcus Aureus Tames Nociceptive Neurons to Suppress Synovial Macrophage Responses for Sustained Infection in Septic Arthritis

The interaction between the nervous system and immune system during chronic bacterial infection remains unclear. Here, it is reported that Staphylococcus aureus (S. aureus) infection induces calcitonin gene-related peptide (CGRP) secretion from intra-articular transient receptor potential cation channel subfamily V member 1 positive (TRPV1+) nociceptive nerves through its pore-forming toxin (PFT) α-hemolysin. The released CGRP then inhibits the production of chemotactic cytokines by CX3CR1+ tissue-resident synovial lining macrophages via receptor activity modifying protein 1 (RAMP1) receptors at the onset of septic arthritis. During the subsequent chronic course of infection, the continuous release of CGRP triggered by pain has a lasting effect on the antimicrobial capabilities of macrophages, thereby promoting bacterial survival and joint damage. This evidence suggests a critical role for neuroimmune regulation in S. aureus-induced chronic septic arthritis. CGRP receptor antagonism may reduce joint destruction, thus providing a new option for treating bone and joint infections.

Outcomes of total hip replacement in adults with septic arthritis of the native hip joint: A systematic review

BACKGROUND

Septic arthritis is a debilitating condition that results in joint destruction and irreversible loss of joint function. Surgical treatment options include arthroscopy, resection arthroplasty, and total hip replacement (THR). Current literature on the treatment of septic arthritis of various joints includes periprosthetic or native joints. However, to our knowledge, a consolidated review that focuses solely on THR outcomes in a previously infected native hip is still lacking. This systematic review, for the first time, examined the clinical outcomes of THR, specifically in adults with septic arthritis of the native hip joint.

METHODS

PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS, Cochrane Library, grey literature, and bibliographic references were searched from inception to October 2023. Only case series or cohort studies published within the last 20 years assessing the outcomes of THR for native hip septic arthritis were included. Literature retrieval and data extraction were conducted by three independent reviewers. Re-infection rate and various functional outcomes, measured in terms of the Harris Hip Score (HHS), Visual Analogue Scale (VAS), Merle D'Aubigne and Postel (MAP), Western Ontario, McMaster Universities Arthritis Index (WOMAC) Short Form 12-Item (SF-12) scores, were analyzed. Range of motion (ROM) and limb length discrepancy (LLD) were also examined.

RESULTS

Against the relevant criteria, seven studies (six case series, one cohort study) involving 1243 patients were included. The patients aged from 18 to 78 years old. The reinfection rate ranged from 0 to 22.8%, with a mean rate of 19.6%. With regards to functional outcomes, the mean increase in HHS was from 39.5 to 48.92 and the increase in MAP ranged from 7.3 to 10.9. Improvement in LLD ranged from 2.28 to 3.52 cm, with all studies reporting < 1 cm of LLD postoperatively.

CONCLUSION

THR, both single and two-staged, is an effective treatment option for septic arthritis of the native hip joint that and yields good functional outcomes and acceptable reinfection rates. However, more prospective and randomized trials are needed to establish clear protocols on antibiotic regimes, clinical criteria clearance, and optimal time from infection to joint replacement.

Clinical characteristics and long-term outcomes of septic arthritis of the native hip joint: a 20-year retrospective review

BACKGROUND

The primary purpose of this retrospective case series was to describe the prevalence and outcomes of single-stage hip arthroplasty in patients who were previously treated for septic arthritis of the native hip at our institution over a 20-year period. This study also examined rates of persistent or recurrent infection, reoperation, and mortality for septic arthritis of the native hip.

METHODS

Adult patients treated for septic arthritis of the native hip at our institution from 1995 to 2015 were retrospectively identified. Exclusion criteria included age <18 years, missing or incomplete medical records, treatment at an outside institution, and prior surgery of the hip.

RESULTS

97 patients were included in this study. 3 patients (3.1%) who were previously treated for septic arthritis of the native hip underwent single-stage hip arthroplasty an average of 40 ± 25 months from the date of infection. 3 of the 18 (16.7%) patients who were treated with resection arthroplasty underwent second-stage joint reconstruction. There were no cases of periprosthetic joint infection (PJI). 1 patient who underwent single-stage arthroplasty experienced implant-induced metallosis, necessitating removal of the implant. There were no other cases of revision arthroplasty.

CONCLUSIONS

The prevalence of single-stage hip arthroplasty in patients with a history of septic arthritis of the native hip joint was 3.1%, which is higher than the prevalence of hip arthroplasty in the United States general population, suggesting that a history of septic arthritis may increase the risk of requiring hip arthroplasty. In the small number of patients who went on to receive a hip replacement, there were no reported cases of PJI. This study suggests that hip arthroplasty is a viable option for patients with symptomatic osteoarthritis and a history of septic arthritis of their hip.

Case Report: Hip arthroplasty after fracture-related joint infection caused by extensively drug-resistant Klebsiella pneumoniae

This case-report focuses on a 23-year-old soldier suffering from a fracture-related hip joint infection (FRI) due to extensively drug-resistant Klebsiella pneumoniae and S. epidermidis. The patient underwent multiple septic revision surgeries including the removal of remaining shrapnel accompanied by last-resort antimicrobial therapy with cefiderocol and colistin. Additionally, the surgeries included repeated tissue sampling for microbiological and histopathological analysis. An antibiotic-loaded cemented filler containing cefiderocol was used to improve local antimicrobial therapy. The biopsies prior to and during hip replacement surgery confirmed successful microbe eradication. Hip arthroplasty restored hip joint function and significantly improved patient's quality of life. The utilization of a trabecular metal shell and a meta-diaphyseally anchored cementless hip stem ensured secure implant fixation and early patient mobilisation. An adjusted biofilm active oral antimicrobial therapy after arthroplasty intervention was continued to prevent early periprosthetic joint infection. This case emphasizes the difficulties of managing FRI and multidrug-resistant pathogens. It contributes valuable insight into navigating complex orthopedic cases while ensuring successful hip arthroplasty outcomes. In conclusion, early interdisciplinary collaboration, appropriate antimicrobial therapy along with tailored surgical interventions are crucial for managing such complex cases successfully.

Advanced imaging shows extra-articular abscesses in two out of three adult patients with septic arthritis of the native hip joint

Background: Septic arthritis (SA) of the native adult hip is a rare orthopaedic emergency requiring prompt diagnosis and treatment. As clinical presentation and laboratory findings are frequently atypical, advanced imaging is often requested. This retrospective study aimed to investigate the prevalence and pattern of extra-articular infectious manifestations and their implications for pre-operative advanced imaging in patients with proven SA of the native hip joint. Methods: Out of 41 patients treated surgically for SA of the native hip during a 16-year period at our tertiary referral hospital, 25 received advanced imaging (computed tomography (CT), magnetic resonance imaging (MRI), or fluorodeoxyglucose positron emission tomography (FDG PET-CT)) prior to initial intervention. For each investigation, a specific set of variables was systematically interpreted, and the most suitable surgical approach was determined. The prognostic value was evaluated by comparing specific outcome measures and the extent of extra-articular involvement. Results: It was found that 32 % of patients had an abscess in one anatomical region, 32 % of patients had abscesses in multiple anatomical regions, and only 36 % of patients had no substantial abscess. Gluteal abscesses were especially common in patients with SA due to contiguous spread. Abscesses in the iliopsoas region were more common in patients with SA due to hematogenous seeding. A combination of several different surgical approaches was deemed necessary to adequately deal with the various presentations. No significant prognostic factors could be identified. Conclusion: We recommend performing advanced imaging in patients with suspected or proven septic arthritis of the native hip joint, as extra-articular abscesses are present in 64 % and might require varying anatomical approaches.

A Midterm Analysis of Outcomes of Septic Arthritis of Hip Treated With Two Stage Cement Spacer and Total Hip Arthroplasty

Objectives

Septic arthritis of the hip, if not managed early and adequately, leads to degenerative arthritis with pain and debility. Various treatment options have been recommended, but no guidelines for the same have been established. Aim of the study is to evaluate the efficacy of our protocol for timing of staging using serological markers, rate of periprosthetic joint infection, midterm implant survivorship and functional outcomes.

Methods

Thirteen patients aged 25 years and above, suffering from degenerative hip arthritis secondary to septic hip, were treated with 2 stage total hip replacement according to our protocol and serological markers were assessed for the timing of stages and follow up of infection control. Outcome of success of two stage total hip arthroplasty was assessed using modified Delphi criteria.

Results

Both the acetabulum and femur head were involved in all cases. Two patients had a history of previous hip surgery. The most common micro-organism detected in intraoperative cultures was Staphylococcus aureus. The mean Harris Hip Score at the final follow-up was 82.33. The outcome was deemed excellent in 84.6 % and good in 15.4 % of cases.

Conclusion

Septic arthritis of the hip leading to end stage degenerative joint disease can be effectively managed with two stage total hip arthroplasty with good to excellent clinical and functional results.

Failure rates in surgical treatment in adults with bacterial arthritis of a native joint: a systematic review of 8,586 native joints

INTRODUCTION

Most adult cases of bacterial-septic-arthritis of a native joint are effectively managed with a single surgical debridement, but some cases may require more than one debridement to control the infection. Consequently, this study assessed the failure rate of a single surgical debridement in adults with bacterial arthritis of a native joint. Additionally, risk factors for failure were assessed.

MATERIALS AND METHODS

The review protocol was registered on PROSPERO (CRD42021243460) before data collection and conducted in line with the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' (PRISMA) guidelines. Multiple libraries were systematically searched to identify articles including patients reporting on the incidence of failure (i.e. persistence of infection requiring reoperation) of the treatment of bacterial arthritis. The quality of individual evidence were assessed using the Quality in Prognosis Studies (QUIPS) tool. Failure rates were extracted from included studies and pooled. Risk factors for failure were extracted and grouped. Moreover, we evaluated which risk factors were significantly associated with failure.

RESULTS

Thirty studies (8,586 native joints) were included in the final analysis. The overall pooled failure rate was 26% (95% CI 20 to 32%). The failure rate of arthroscopy and arthrotomy was 26% (95% CI 19 to 34%) and 24% (95% CI 17 to 33%), respectively. Seventy-nine potential risk factors were extracted and grouped. Moderate evidence was found for one risk factor (synovial white blood cell count), and limited evidence was found for five risk factors (i.e. sepsis, large joint infection, the volume of irrigation, blood urea nitrogen-test, and blood urea nitrogen/creatinine ratio).

CONCLUSION

A single surgical debridement fails to control bacterial arthritis of a native joint in approximately a quarter of all adult cases. Limited to moderate evidence exists that risk factors associated with failure are: synovial white blood cell count, sepsis, large joint infection, and the volume of irrigation. These factors should urge physicians to be especially receptive to signs of an adverse clinical course.

Should treatment decisions in septic arthritis of the native hip joint be based on the route of infection?

Background: Surgical management of septic arthritis (SA) of the hip aims at treating the infection by either preserving, resecting or replacing the joint. In some cases, joint preservation should be attempted, whereas other cases would benefit from immediate joint resection or replacement. Prognostic factors have been proposed to guide decision-making. We hypothesized that most of these factors can be simplified to three subgroups based on the route of infection: contiguous spreading, direct inoculation or hematogenous seeding. Methods: A total of 41 patients have been treated surgically for SA of the native hip at our tertiary hospital during the last 16 years. Medical records were studied, and various patient and disease characteristics were collated. Results: Significant differences between (1) level of fitness, (2) condition of the hip joint, (3) micro-organisms and (4) chance of femoral head preservation were found for patients with SA of the native hip resulting from the three aforementioned subgroups. Femoral head resection was necessary at one point in 85 % of patients. Patients with hematogenous infections of undamaged hips had a reasonable chance (53 %) of avoiding joint resection or replacement. Hip arthroplasty was performed on 46.3 % of patients, with an infection rate of 10.5 %. Conclusion: Patients with SA of the native hip resulting from contiguous spreading, hematogenous seeding or direct inoculation differ significantly and should be considered distinct clinical entities. Route of infection is directly related to the chance of femoral head preservation and should, therefore, guide decision-making. Only patients with hematogenous infection to a previously healthy hip had the possibility of femoral head preservation.

Acute multifocal osteomyelitis with septic arthritis caused by nontyphoidal Salmonella in an immunocompetent young adult: a case report

Nontyphoidal Salmonella (NTS) infection can lead to gastroenteritis, enteric fever, and bacteremia. However, bone and joint infections due to NTS are rarely encountered, accounting for only 0.8% of all Salmonella infections and 0.45% of all types of osteomyelitis. We herein report an extremely rare case of acute multifocal osteomyelitis (bilateral femurs and left tibia) with septic arthritis of the bilateral hips caused by Salmonella Dublin in an immunocompetent adult. We performed thorough debridement of the bilateral hips and surgical decompression of the involved bones. At 1 year of follow-up, the patient's inflammatory biomarkers were within normal limits, and clinical and radiologic examinations showed no signs of infection. We emphasize that invasive NTS can lead to multifocal bone and joint infections in immunocompetent adults. The manifestations of Salmonella osteomyelitis may be insidious; thus, we recommend performing a simultaneous magnetic resonance imaging examination of the bone adjacent to the infected joint to avoid missed or delayed diagnosis. Thorough surgical debridement combined with a long course of sensitive antibiotic therapy is essential to eradicate the infection.

Septic arthritis with osteomyelitis due to Salmonella enterica serotype Dublin: A case series

Background

Septic arthritis with osteomyelitis due to Salmonella enterica serotype Dublin is rare. We reviewed and analyzed cases of septic arthritis with osteomyelitis due to Salmonella enterica serotype Dublin seen at our institution.

Methods

The medical records of all patients diagnosed with Salmonella septic arthritis and/or Salmonella osteomyelitis during 2017-2022 were included. We reviewed the diagnosis, medical history, clinical management, and outcome of all cases.

Results

Five patients with Salmonella septic arthritis or Salmonella osteomyelitis were identified during the 5-year study period. They were all male; the median age was 53 years (range 15-56). Only one was immunodeficient. All five patients were infected at the hip joint and ipsilateral femur, while two suffered bilateral hip septic arthritis with femoral osteomyelitis. Salmonella Dublin was isolated from the hip joint fluid of all patients. Four presented with fever and constitutional signs within four weeks of symptom onset. Four had positive blood cultures, and only one patient had gastrointestinal symptoms. Four patients underwent surgical debridement as the primary surgical plan, and two underwent secondary two-stage exchange after primary surgical debridement failure. The last patient had a two-stage exchange directly as the first surgical treatment. All patients received intravenous antimicrobial therapy for a median duration of 6 (range 4-12) weeks and oral antimicrobial therapy for a median duration of 4 (range 4-6) weeks. All patients had a median duration of follow-up of 12 months (range 9-25), and none had evidence of recurrence of infection.

Conclusions

Septic arthritis due to Salmonella Dublin remains rare. It frequently occurs with ipsilateral femur osteomyelitis adjacent to the infected hip joint in our cases. Surgical debridement or two-stage exchange, along with 4-12 weeks of effective intravenous and followed by 4-6 oral antimicrobial therapy, could successfully eradicate the infection.

Prior Septic Arthritis Within One Year of Knee Arthroplasty is Associated With a High Risk for Infection

BACKGROUND

A prior history of a septic knee may predispose patients to a periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). We performed multivariate analyses of known risk factors that portend a periprosthetic infection for patients who have a history of septic arthritis (SA). The focus of the study was an assessment of the incidence of TKA PJIs at various time intervals after the onset of a septic knee (0 to 3 months, 3 to 6 months, 6 to 9 months, and 9 months to 1-year).

METHODS

We queried a national database to identify patients who underwent a primary TKA between 2010 and 2021 (n = 1.9 million). Patients who had a prior septic knee ipsilateral to the primary TKA were characterized (n = 4,251) and were put into four specific cohorts based on the interval between the SA diagnosis and TKA: less than 3 months; 3 to 6 months; 6 to 9 months; and 9 to 12 months. A cohort of patients who did not have history of septic knee were used for comparison (n = 5,000). The incidence of PJIs from 90 days to 1 year was identified and compared using multivariate analyses.

RESULTS

All time cohorts were more likely to require revisions due to PJI, as compared to the comparison group. Significant differences were demonstrated among all time cohorts who had prior SA compared to patients who did not have a history of SA (odds ratio [OR] range, 90.0 to 113.0, P < .001).

CONCLUSION

This study has shown an increased PJI risk in the first year after SA (P < .05). The surgeon should be aware of the increased PJI risk after SA within the first year after TKA.

Less Than 1-Year Quiescent Period After Septic Arthritis of the Hip is Associated With High Risk of Periprosthetic Joint Infection Following Total Hip Arthroplasty

BACKGROUND

Approximately 20,000 patients are diagnosed with septic arthritis annually, with 15% specifically affecting the hip joint. These cases exacerbate arthritic changes, often warranting a total hip arthroplasty (THA). Given their prior history of infection, these patients are predisposed to subsequent periprosthetic joint infections (PJIs). Multiple studies suggest delaying THA after a native septic hip, but no study utilizing a large cohort examined the specific timing to mitigate post-THA PJI risk within a short (<1 year) quiescent period after septic arthritis. We sought to compare patients who were diagnosed with septic hip arthritis at time intervals (0-6, or 6-12 months) prior to an ipsilateral primary THA to a cohort of THA patients who never had a septic hip history. Specifically, we assessed: from 90 days to 2 years (1) revisions due to PJI and (2) associated risk factors for PJI at 2-years.

METHODS

A national, all-payer database was queried to identify all patients who underwent a primary THA between 2010 and 2021 and patients who had prior ipsilateral septic hip arthritis were characterized using International Classification of Disease and Current Practice Terminology codes (n = 1,052). A randomized sample of patients who never had a history of septic arthritis prior to undergoing THA was used as a nonseptic group comparison (n = 5,000). The incidences of PJI at 90 days through two years were then identified and compared using bivariate chi-square analyses. Risk factors for post-THA PJIs were then analyzed using multivariate regression models.

RESULTS

The septic arthritis cohorts were more likely to require revisions due to PJIs, as compared to the non-septic group at 90 days, 1 year, and 2 years (all P < .0001). Patients who were diagnosed with septic arthritis between 0 and 6 months prior to THA were at greater PJI risk at both one-year (odds ratio (OR) of 43.1 versus 29.6, P < .0001) and two years (OR of 38.3 versus 22.1, P < .0001) compared to patients who had diagnoses between 6 and 12 months. Diabetes mellitus, obesity, and tobacco use were associated risk factors for PJIs at 2 years in the septic hip cohort in comparison to the cohort without a septic hip history.

CONCLUSION

Less than a 1-year quiescent period after septic arthritis is associated with a 38 times increased risk and a 22 times risk for post-THA PJI, at 0 and 6 months and 6 and 12 months, respectively. Though patients who undergo THA greater than 6 months after their septic arthritis treatment have a decreased risk compared to those between 0 and 6 months the risks are still high. Orthopaedic surgeons should be aware of the increased risks of PJIs when considering performing a THA in patients with a history of septic arthritis.

Multiple organ failure and death caused by Staphylococcus aureus hip infection: A case report

Suppurative arthritis has an acute onset and mostly affects old people and children. Recently, the incidence of adult suppurative hip arthritis, as well as its serious consequences, has increased. The deep hip joint and surrounding hypertrophic muscle tissue limit physical examination. Furthermore, they may cause variable and atypical symptoms of suppurative hip arthritis, possibly inducing delayed diagnosis and treatment. This atypical presentation is uncommon, causing delayed diagnosis and treatment, thus worsening the outcomes. We herein report the case of a 58-year-old man with Staphylococcus aureus (S. aureus) septicemia and multiple organ failure due to left pyogenic arthritis of the hip. The patient's early symptoms were extremely atypical given that he only presented hip pain. Moreover, there was no obvious history of trauma or inflammatory manifestations, such as fever or local swelling, and laboratory examination results and imaging findings were atypical. However, the disease progressed rapidly, developing into systemic sepsis within a short period of time followed by multiple organ failure and death. Early diagnosis and effective treatment of S. aureus hip arthritis are essential to avoid poor outcomes.

Management of septic arthritis of the hip joint in adults. A systematic review of the literature

BACKGROUND

The septic arthritis of the hip is a complex condition characterized by a variety of clinical presentations, a challenging diagnosis and different surgical treatment options, including arthroscopy, resection arthroplasty and one and two-stage total hip replacement. Each technique reports variable results in terms of infection eradication rate. The aim of this systematic review is to compare the most relevant studies available in current literature and to assess if a better treatment outcome can be predicted based on the microbiology, history, and type of infection (active vs quiescent) of each case.

METHODS

A systematic review of the literature was performed in accordance with the PRISMA guidelines, including the studies dealing with the treatment of hip septic arthritis in adult patients. Electronic databases, namely the MEDLINE, Scopus, and Web of Science, were reviewed using a combination of following keywords "septic arthritis" AND "hip joint" OR "hip" AND "adult".

RESULTS

The total number of patients included in this review was 1236 (45% of which females), for 1238 hips. The most common pathogen isolated was Staphylococcus aureus in its Methicillin-sensitive variant ranging from 2 to 37% of cases. Negative cultures were the second most common finding. It was also differentiated the type of infection of the hip, 809 and 417 patients with active and quiescent hip infection, respectively, were analyzed. Eradication rates for two-stage revision arthroplasty ranged between 85 and 100%, for one-stage approach between 94 and 100%, while for arthroscopic debridement/lavage between 89 and 100%.

CONCLUSION

Staphylococcus aureus is the most common microorganism isolated followed by culture negative infections. Arthroscopic, one and two stage procedures can be effective in the treatment of hip septic arthritis when the indication is consistent with the type of infection retrieved.

LEVEL OF EVIDENCE

IV, therapeutic study.